The health care system is broken into primary, secondary, and tertiary structures, of which patients should seek care in that ordered progression (from primary to tertiary centers). There are 1680 primary health care centers, which provide basic services, such as general medicine, pediatrics and obstetrics, and house no inpatients. There are 183 secondary and tertiary facilities. The secondary facilities, or hospitals, can have specialties like psychologists, surgeons and a laboratory. The tertiary hospitals, normally just one, sometimes two, per region, offer more specialized care.
The tertiary hospitals and clinics are often overcrowded, due, in large part, to the perception that a person can directly receive the care they need, without having to spend the time getting evaluated and referred from the primary to secondary and then secondary to tertiary facility. People often need referrals because the primary, and even secondary, care facilities cannot provide the necessary services, often due to a lack of equipment and medicines.
To combat the overcrowding of the tertiary care facilities, a new strategy is just recently being implemented to "remodel" the system. The focus now is on primary health care, since it had been on tertiary care in the past, as well as reinforcing the idea of the progression from primary to secondary to tertiary care.
To improve primary care, focus is shifting towards producing more primary care doctors and less specialists (as there is a relative surplus). Additionally, the goal is to provide better incentives for doctors to move to areas of the country outside of Santo Domingo or Santiago - the country's two largest cities. Furthermore, there is a lack of continuing education offerings for physicians, so programs that would provide that education would help; currently, it often happens that doctors will receive their four years of education and keep working ... without learning new things.